Download Maria Milian Sobarzo MD, PA 21402 Provincial Blvd Katy TX 77450

Maria Milian Sobarzo M.D., P.A.
21402 Provincial Blvd
Katy TX 77450
281.398.0777
Patient Name: Last ______________________ First ____________________ Middle ___________
Address: __________________________________________ City, State, Zip __________________
Tel: Home ___________________ Work ____________________ Cell _______________________
Check one: Employed ____ F/T Student ____ P/T Student ____ Unemployed _____
Check one: Single ____ Married ____ Other ____ Drivers Lic # ___________________________
Patient
Spouse/Parent
Employer/School ____________________________ Name _________________________________
Address ____________________________________ Work Number __________________________
SS# _______________________________________ SS# ___________________________________
Date of Birth ________________________________ Date of Birth ___________________________
Referred by: Physician _____
Friend _________
Name: ________________________________________________
Self ________
Next of Kin: _______________________________ Tel: __________________________________
Relative of Friend not living at same address:
Name: __________________________________ Relationship ______________________________
Address ___________________________________________ Tel ____________________________
Primary Insurance
Ins Co ___________________________________
Secondary Insurance
______________________________________
Claims Address ___________________________
______________________________________
City, St, Zip ______________________________
______________________________________
Group Number ____________________________
______________________________________
Policy/Id # _______________________________
______________________________________
Assignment of Insurance Benefits and Authorization to release Information:
I authorize payment of medical benefits to Maria Milian Sobarzo MD for any and all services
rendered.
I authorize Maria Milian Sobarzo MD to release any medical information necessary for the processing
of my medical insurance claims.
Patient _________________________________________ Date ______________________________
Responsible Party Signature _____________________________ Relationship ___________________
Date ______
Date _________________ Name __________________________________ Age ________
Genetic: If you or your husband are in the following categories, please respond Yes or No
African American or Indian descent, have you or your husband had Sickle Cell carrier testing? ____
Italian or Greek descent, have you or your husband had Thalassemia carrier testing? _______
Jewish descent, have you or your husband had Tay-Sachs carrier testing? _______
Additional explanation of past history __________________________________________________
_________________________________________________________________________________
Race _____________________________ Occupation _____________________________________
Do you drink Alcohol? ______ If yes, estimated number of drinks per week ____________________
Do you smoke? ______ How many packs per day? ________________
Are you using any other drugs? ___________ Type? _______________________________________
Are you sexually active? _____ Any difficulties or discomfort? ______________________________
Family History: Is there a member of your family with a history of:
_____ Cancer – Type: __________
Who? ____________________________
_____ Congenital (Inherited) Disease
Who? ____________________________
_____ Diabetes
Who? ____________________________
_____ Heart Disease
Who? ____________________________
_____ High Blood Pressure
Who? ____________________________
_____ High Cholesterol
Who? ____________________________
_____ Kidney Disease
Who? ____________________________
_____ Mental Retardation
Who? ____________________________
_____ Osteoporosis
Who? ____________________________
_____ Twins
Who? ____________________________
Date of Last Pap Smear _________________ Results ____________________________
Date of Last Mammogram ______________ Results ____________________________
Date of Last Bone Density ______________ Results ____________________________
Reason for today’s visit ____________________________________________________
________________________________________________________________________
What changes have there been in your life recently? ______________________________
Pharmacy Name and Phone # ________________________________________________
Do you need 30 or 90 day prescriptions? _______________________________________
Date _________________ Name ________________________________
Age _________
Past History: Circle all that apply
Arthritis
Asthma
Breast Tumor
Diabetes
Heart Attack
Hepatitis
High Blood Pressure
High Cholesterol
Intestinal Bleeding
Heart Murmur
Migraine Headaches
Mitral Valve Prolapse
Neurological Disease
Osteoporosis
Kidney Infection
Rheumatic Fever
Thrombophlebitis
Thyroid Problems
Pneumonia
Kidney Stone
Other Heart Disease ________________
Infectious Disease (TB, HIV, etc) ______________
Other Kidney Disease _______________
Other Lung Disease _________________________
Other __________________________________________________________________________
List all Surgeries
Type of Surgery
Date
1. _______________________________
Type of Surgery
Date
3. _______________________________________
2. _______________________________
4. _______________________________________
Number of:
Pregnancies ____ Deliveries ____ Miscarriages ____ Abortions ____ Living Children _____
Please list pregnancies in chronological order:
Date
Sex
Wt
Type of Delivery
Complications
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Will you permit a Blood Transfusion for medical reasons? __________
Date of last menstrual period ______________ Are your periods regular? ______________
Any problems with periods? ____________________ Present type of Birth Control ____________
Do you want to change birth control? ___________ To what? ______________________________
Did your mother take DES or other hormones while pregnant with you? ______________________
Female Organs: Circle any that you have had
Abnormal Bleeding
Herpes Infection
Tubal (Ectopic) Pregnancy
Chlamydia/Gonorrhea/Syphilis
Infection of Tubes or Ovaries
Tumor of Uterus or Ovaries
Genital Warts
Abnormal Pap Smear ________Treatment __________________________________________________
List all currently used medications ________________________________________________________
_____________________________________________________________________________________
List all allergies to medications ___________________________________________________________